MENTAL HEALTH EXAM 2 1023
QUESTIONS AND ANSWERS WITH
COMPLETE LATEST UPDATED 2026
Question: Which nursing diagnosis takes precedence for a patient
undergoing alcohol withdrawal?
A. Risk for injury r/t central nervous system stimulation B. Disturbed thought
processes r/t tactile hallucinations C. Ineffective coping r/t powerlessness over
alcohol use D. Ineffective denial r/t continued alcohol use despite negative
consequences
Answer: ✔️✔️ A. Risk for injury r/t central nervous system stimulation.
Rationale: Safety is the primary concern because alcohol withdrawal triggers
significant CNS hyperactivity. This can lead to dangerous physiological
symptoms such as seizures, severe tremors, tachycardia, hypertension, and
hallucinations, all of which pose an immediate physical threat to the patient.
Question: A nurse reviews a patient's PCA (patient-controlled analgesia)
pump and identifies 50 delivery attempts in just 15 minutes. What is the
clinical justification for screening this patient for a history of substance use
disorder?
A. Narcotic pain medication is contraindicated for all clients with active
substance use disorders. B. Clients who are addicted to alcohol or
benzodiazepines may develop cross-tolerance to analgesics and require
increased doses to achieve effective pain control. C. There is no need to assess
for addiction; high attempt rates always indicate a mechanical PCA malfunction.
D. The client is purely experiencing withdrawal and the PCA attempts are
irrelevant to pain levels.
Answer: ✔️✔️ B. Clients who are addicted to alcohol or benzodiazepines may
develop cross-tolerance to analgesics and require increased doses to achieve
effective pain control.
Rationale: Chronic use of substances like alcohol or benzodiazepines can lead
to "cross-tolerance," where the body becomes less sensitive to other CNS
,depressants, including opioid analgesics. In these cases, the patient may require
higher-than-average doses to achieve the same level of therapeutic pain relief.
On the first day of a client's alcohol detoxification, which nursing intervention
should take priority?
A. Strongly encourage the client to attend 90 AA meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer orders chlordiazepoxide (Librium) in dosage according to
protocol.
D. Provide thiamin supplements to prevent Wenicke-Korsakoff syndrome. -
ANSWER ✔️✔️Answer: C. Administer orders chlordiazepoxide (Librium) in
dosage according to protocol.
Rationale: Priority nursing intervention for this client should be to administer
ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is
a benzodiazepine and is often used for medication-assisted therapy in alcohol
withdrawal to reduce life-threatening complications.
Which client statement indicated a knowledge deficit related to a substance use
disorder?
A. "Although it's legal, alcohol is one of the most widely abused drugs in our
society"
B. "Tolerance to heroin develops quickly"
C. "Flashbacks form lysergic acid diethyl amide (LSD) use may reoccur
spontaneously."
D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially
harmless'' -ANSWER ✔️✔️Answer: D. Marijuana is like smoking cigarettes.
Everyone does it. It's essentially harmless''
,Rationale: The nurse should determine that the client has a knowledge deficit
related to substance use disorder when the client compares marijuana to
smoking cigarettes and claims it to be harmless. The evidence of research
indicates that smoked marijuana is harmful.
A lonely, depressed divorcée has been self-medicating with small amounts of
cocaine for the past year. Which term should a nurse use to best describe this
individual's situation?
A. Psychological addiction
B. Codependence
C. Substance induced disorder
D. Intoxication -ANSWER ✔️✔️Answer: A. Psychological addiction
Rationale: The nurse should use therm psychological addiction to best describe
the client's situation. A client is considered to be psychologically addicted to a
substance when there is an overwhelming desire to use a drug in order to
produce pleasure (feel better) or avoid discomfort.
Which term should a nurse use to describe the administration of a central
nervous system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Medication-assisted treatment -ANSWER ✔️✔️Answer: D. Medication-
assisted treatment
, Rationale: Various medications have been used to decrease the intensity of
symptoms in an individual who is withdrawing from, or who is experiencing the
effects of excessive use of, alcohol and other drugs. This is called medication-
assisted treatment.
A client diagnosed with chronic alcohol dependency is being discharged from an
inpatient treatment facility after detoxification. Which client outcome related to
Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss
with the client during discharge teaching?
A. To immediately attend AA meetings at least weekly
B. To rely on an AA sponsor to help control alcohol cravings
C. To incorporate family in AA attendance
D. To seek appropriate deterrent medications through AA -ANSWER
✔️✔️Answer: A. To immediately attend AA meetings at least weekly
Rationale: The most appropriate client outcome for the nurse to discuss during
discharge teaching is attending AA meetings at least weekly. AA is a major self-
help organization for the treatment of alcohol addiction. It accepts alcohol
addiction as an illness and promotes total abstinence as the only cure.
A client with a history of alcohol use disorder is brought to an emergency
department (ED) by family members who state that the client has had nothing to
drink in the last 48 hours. When the nurse reports to the ED physician, which
client sign or symptom should be the nurse's first priority
A. Hearing and visual impairment
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration -ANSWER ✔️✔️Answer: B. Blood pressure of 180/100 mm Hg
QUESTIONS AND ANSWERS WITH
COMPLETE LATEST UPDATED 2026
Question: Which nursing diagnosis takes precedence for a patient
undergoing alcohol withdrawal?
A. Risk for injury r/t central nervous system stimulation B. Disturbed thought
processes r/t tactile hallucinations C. Ineffective coping r/t powerlessness over
alcohol use D. Ineffective denial r/t continued alcohol use despite negative
consequences
Answer: ✔️✔️ A. Risk for injury r/t central nervous system stimulation.
Rationale: Safety is the primary concern because alcohol withdrawal triggers
significant CNS hyperactivity. This can lead to dangerous physiological
symptoms such as seizures, severe tremors, tachycardia, hypertension, and
hallucinations, all of which pose an immediate physical threat to the patient.
Question: A nurse reviews a patient's PCA (patient-controlled analgesia)
pump and identifies 50 delivery attempts in just 15 minutes. What is the
clinical justification for screening this patient for a history of substance use
disorder?
A. Narcotic pain medication is contraindicated for all clients with active
substance use disorders. B. Clients who are addicted to alcohol or
benzodiazepines may develop cross-tolerance to analgesics and require
increased doses to achieve effective pain control. C. There is no need to assess
for addiction; high attempt rates always indicate a mechanical PCA malfunction.
D. The client is purely experiencing withdrawal and the PCA attempts are
irrelevant to pain levels.
Answer: ✔️✔️ B. Clients who are addicted to alcohol or benzodiazepines may
develop cross-tolerance to analgesics and require increased doses to achieve
effective pain control.
Rationale: Chronic use of substances like alcohol or benzodiazepines can lead
to "cross-tolerance," where the body becomes less sensitive to other CNS
,depressants, including opioid analgesics. In these cases, the patient may require
higher-than-average doses to achieve the same level of therapeutic pain relief.
On the first day of a client's alcohol detoxification, which nursing intervention
should take priority?
A. Strongly encourage the client to attend 90 AA meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer orders chlordiazepoxide (Librium) in dosage according to
protocol.
D. Provide thiamin supplements to prevent Wenicke-Korsakoff syndrome. -
ANSWER ✔️✔️Answer: C. Administer orders chlordiazepoxide (Librium) in
dosage according to protocol.
Rationale: Priority nursing intervention for this client should be to administer
ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is
a benzodiazepine and is often used for medication-assisted therapy in alcohol
withdrawal to reduce life-threatening complications.
Which client statement indicated a knowledge deficit related to a substance use
disorder?
A. "Although it's legal, alcohol is one of the most widely abused drugs in our
society"
B. "Tolerance to heroin develops quickly"
C. "Flashbacks form lysergic acid diethyl amide (LSD) use may reoccur
spontaneously."
D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially
harmless'' -ANSWER ✔️✔️Answer: D. Marijuana is like smoking cigarettes.
Everyone does it. It's essentially harmless''
,Rationale: The nurse should determine that the client has a knowledge deficit
related to substance use disorder when the client compares marijuana to
smoking cigarettes and claims it to be harmless. The evidence of research
indicates that smoked marijuana is harmful.
A lonely, depressed divorcée has been self-medicating with small amounts of
cocaine for the past year. Which term should a nurse use to best describe this
individual's situation?
A. Psychological addiction
B. Codependence
C. Substance induced disorder
D. Intoxication -ANSWER ✔️✔️Answer: A. Psychological addiction
Rationale: The nurse should use therm psychological addiction to best describe
the client's situation. A client is considered to be psychologically addicted to a
substance when there is an overwhelming desire to use a drug in order to
produce pleasure (feel better) or avoid discomfort.
Which term should a nurse use to describe the administration of a central
nervous system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Medication-assisted treatment -ANSWER ✔️✔️Answer: D. Medication-
assisted treatment
, Rationale: Various medications have been used to decrease the intensity of
symptoms in an individual who is withdrawing from, or who is experiencing the
effects of excessive use of, alcohol and other drugs. This is called medication-
assisted treatment.
A client diagnosed with chronic alcohol dependency is being discharged from an
inpatient treatment facility after detoxification. Which client outcome related to
Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss
with the client during discharge teaching?
A. To immediately attend AA meetings at least weekly
B. To rely on an AA sponsor to help control alcohol cravings
C. To incorporate family in AA attendance
D. To seek appropriate deterrent medications through AA -ANSWER
✔️✔️Answer: A. To immediately attend AA meetings at least weekly
Rationale: The most appropriate client outcome for the nurse to discuss during
discharge teaching is attending AA meetings at least weekly. AA is a major self-
help organization for the treatment of alcohol addiction. It accepts alcohol
addiction as an illness and promotes total abstinence as the only cure.
A client with a history of alcohol use disorder is brought to an emergency
department (ED) by family members who state that the client has had nothing to
drink in the last 48 hours. When the nurse reports to the ED physician, which
client sign or symptom should be the nurse's first priority
A. Hearing and visual impairment
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration -ANSWER ✔️✔️Answer: B. Blood pressure of 180/100 mm Hg
